MDCalc Wars: Alcohol Withdrawal–When CIWA-Ar Breaks Down, mMINDS Score Still Works

Written by Eric Steinberg DO, MEHP
REBEL EM
Medical Category: Toxicology
Alcohol Withdrawal, autonomic instability, Benzodiazepines, CIWA-Ar, delirium tremens, MDCalc, MDCalc Wars, mMINDS, Phenobarbital, withdrawal scoring

January 26, 2026

🗝️ Key Points

🗣️ CIWA-Ar needs patient participation — it works best when the patient is awake, verbal, and reliable.
🏥 In severe/ICU withdrawal, CIWA-Ar breaks down — intubation, delirium, sedation, or critical illnessmake symptom reporting unreliable.
🎯 mMINDS is the ICU-ready alternative — it emphasizes objective findings (vitals + agitation/tremor/diaphoresis) and can be used when the patient can’t participate.
🔁 Trend the score, don’t one-and-done it — serial mMINDS reassessments help guide symptom-triggered escalation and monitor response.
⚠️ Watch for mimics — tachycardia/agitation may reflect pain, sepsis, hypoxia, intoxication, or delirium, so treat the patient, not just the number.

🤕 Case

Mark, a 52-year-old man with long-standing alcohol use disorder, presents to the ED 12 hours after his last drink with worsening tremors, agitation, nausea, and diaphoresis. Vitals show T 37.8 °C, HR 122, BP 178/94. He is visibly anxious, diaphoretic, tachycardic, and intermittently confused, with coarse hand tremors and pressured speech. He struggles to answer questions reliably and becomes increasingly restless despite initial benzodiazepine dosing. You turn to the reliable CIWA-Ar, but that depends on patient participation—so what do you use when that’s not possible?

🔗 Scoring Tools

➡️ CIWA-Ar for Alcohol Withdrawal

➡️ Modified Minnesota Detoxification Scale (mMINDS)

🎯 Quick Hits

💬 Case Resolution

Using the mMINDS score, the team objectively assessed withdrawal severity despite limited patient participation. They escalated treatment with symptom-triggered therapy. Guided by serial mMINDS reassessments, his agitation and autonomic instability steadily improved without progression to seizures or delirium tremens. He was safely admitted for monitored care and ultimately discharged with addiction medicine follow-up and a clear recovery plan.

❓ FAQ: mMINDS vs CIWA-Ar

What is the mMINDS score used for?
mMINDS (modified Minnesota Detoxification Scale) is used to assess the severity of alcohol withdrawal when patient participation is limited, especially in critically ill/ICU patients. It leans on more objective findings (e.g., vitals, tremor, diaphoresis, agitation/sedation scales) rather than patient-reported symptoms.
Why doesn’t CIWA-Ar work in intubated or delirious patients?
CIWA-Ar includes multiple elements that require a patient to answer subjective questions (e.g., anxiety, nausea, hallucinations) and communicate reliably. In intubation, delirium, psychosis, or severe critical illness, those inputs become impossible or unreliable, so CIWA-Ar can’t be completed accurately and may mislead care.
When should I use mMINDS instead of CIWA-Ar?
Use mMINDS when the patient is ICU-level or can’t reliably participate—examples: intubated, delirious, nonverbal, heavily sedated, or otherwise unable to provide consistent symptom reporting. The ASAM guideline specifically recommends using a scale that relies more on objective signs when communication is difficult.
How often should mMINDS be reassessed in severe withdrawal?
Reassessment cadence is protocol-dependent, but in many hospital pathways it becomes more frequent as severity increases. Commonly used MINDS protocol checks scores q2h (mild), q1h (moderate), and q20min (severe) during active titration/escalation.
Can tachycardia or agitation inflate mMINDS if the cause isn’t withdrawal?
Yes. Autonomic signs and agitation are not specific to alcohol withdrawal and can reflect pain, hypoxia, sepsis, intoxication, medication effects, or primary delirium. Guidelines recommend assessing whether withdrawal scales may be confounded by other causes and interpreting scores cautiously when those risks exist.
Does mMINDS replace CIWA-Ar for mild floor-level withdrawal
Usually no. CIWA-Ar remains appropriate for stable, communicative patients and is widely used/validated in general inpatient settings, whereas mMINDS is mainly valuable when objectivity is needed and CIWA-Ar isn’t feasible (often ICU/non-communicative scenarios).

🚨 Clinical Bottom Line

CIWA-Ar: Use for stable, communicative patients.
mMINDs: Reach for it in severe or ICU-level withdrawal when objectivity is paramount.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_Propersi), and Mark Ramzy, DO (X: @MRamzyDO)

🧭 Prep Sheets

CIWA-Ar for Alcohol Withdrawal

Modified Minnesota Detoxification Scale (mMINDS)

👤 Author

Eric Steinberg

DO, MEHP

Content Director, MDCalc, Residency Director, Emergency Medicine St. Joseph's University Medical Center, Paterson, NJ

Meet The Team

🔎 Your Deep-Dive Starts Here

Cite this article as: Eric Steinberg DO, MEHP, "MDCalc Wars: Alcohol Withdrawal–When CIWA-Ar Breaks Down, mMINDS Score Still Works", REBEL EM blog, January 26, 2026. Available at: https://rebelem.com/mdcalc-wars-alcohol-withdrawal-when-ciwa-ar-breaks-down-mminds-score-still-works/.